Provider Demographics
NPI:1891793105
Name:VERNON, JOHN E (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:E
Last Name:VERNON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12680 OLIVE BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-6322
Mailing Address - Country:US
Mailing Address - Phone:314-251-8900
Mailing Address - Fax:
Practice Address - Street 1:12680 OLIVE BLVD STE 100
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-6322
Practice Address - Country:US
Practice Address - Phone:314-251-8900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2018-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001031156207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208988501Medicaid
MO208988501Medicaid
916970198Medicare ID - Type Unspecified